Information Collection

Application for Health Center Program Recipients for Deemed Public Health Service Employment with Liability Protections Under the Federal Tort Claims Act (FTCA)

IC 230498 under ICR 202203-0906-003 · OMB 0906-0035.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Application for Health Center Program Recipients for Deemed Public Health Service Employment with Liability Protections Under the Federal Tort Claims Act (FTCA)	Form and Instruction
Calendar Year 2023 Health Center Application Tracked Changes.docx	Other-Redline
Calendar Year 2023 Health Center Application Tracked Changes.docx	Other-Redline
1 CY 2023 Health Center APPLICATION ONLY 3.2.22 CY 2023 Health Center APPLICATION ONLY 3.2.22.docx	Form and Instruction
1 CY 2023 Health Center APPLICATION ONLY 3.2.22 CY 2023 Health Center APPLICATION ONLY 3.2.22.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Application for Health Center Program Recipients for Deemed Public Health Service Employment with Liability Protections Under the Federal Tort Claims Act (FTCA)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	CY 2023 Health Center APPLICATION ONLY 3.2.22	CY 2023 Health Center APPLICATION ONLY 3.2.22.docx		Yes	Yes	Fillable Fileable
Other-Redline			Calendar Year 2023 Health Center Application Tracked Changes.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,160

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,160	1,160
Annual IC Time Burden (Hours)	2,900	2,900
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.